title: The impact of primary care dual-management on quality of care.
abstract: BACKGROUND
  Discontinuity is common in US healthcare. Patients access multiple systems of care and in the nation's largest integrated healthcare system, Veteran's Administration (VA) patients frequently use non-VA primary care providers. The impact of this "dual-management" on quality is unknown. The authors' objective was to identify dual-management and associations with markers of care quality for hypertension and associated conditions.
  
  
  METHODS
  Data was collected via surveys and chart reviews of primary care patients with hypertension from six VA clinics in Iowa and Minnesota. Clinical measures abstracted included the following: goal blood pressure (BP) and use of guideline-concordant therapy, low-density lipoprotein (LDL) cholesterol, hemoglobin A1C, and body mass index (BMI). Dual-management data was obtained through self-report.
  
  
  RESULTS
  Of 189 subjects (mean age = 66), 36% were dual-managed by non-VA providers. There was no difference in hypertension quality of care measures by dual-management status. A total of 51% were at BP goal and 58% were on guideline-concordant therapy. Dual-managed patients were more likely to use thiazide diuretics (43% vs 29%; P = .03) and angiotensin receptor blockers (13% vs 3%; P < .01), but less likely to use angiotensin-converting enzyme inhibitors (43% vs 61%; P = .02). There was no difference in LDL cholesterol (97.1 mg/dl vs 100.1 mg/dl; P = .55), hemoglobin A1C (7% vs 6%; P = .74), or BMI (29.8 vs 30.9; P = .40) for dual-managed versus VA managed patients, respectively.
  
  
  CONCLUSIONS
  Although dual-management may decrease continuity, VA/private sector dual-management did not impact quality of care, though some medication differences were observed. With the high prevalence of dual-management, future work should further address quality and evaluate redundancy of services.
authors.affiliation: Iowa City VA Healthcare System, Iowa City, IA, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kaboli
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Shivapour
authors.forename: Michael S
authors.initials: MS
authors.lastname: Henderson
authors.forename: Areef
authors.initials: A
authors.lastname: Ishani
authors.forename: Mary E
authors.initials: ME
authors.lastname: Charlton
keywords: health outcomes; impact evaluation; obesity; prevention; primary care